Causes of Heel Pain

Possible Causes and Differential Diagnosis for Heel Pain

Plantar Fasciitis: The most common cause for heel pain is plantar fasciitis. This condition is known for causing pain at the bottom of the heel and sometimes in the arch. Plantar fasciitis is characterized by heel pain at the first step in the morning, which can sometimes be so severe that many will limp, or grab onto a wall in order to make their way to the bathroom. After 20-30 minutes, the pain tends to work itself out. More images, pictures diagrams and treatments for plantar fasciitis.

Plantar Fascial Rupture: The plantar fascia is a long ligament on the bottom of the foot which helps to support the arch. A complete tear of this ligament, at the heel, is rare but can happen. Generally, individuals have some dull pain in the heel prior to the injury, but not severe enough to seek medical attention. Acute pain can develop after jumping and landing on the foot or taking off quickly in a sprint.

This is common in games like tennis or soccer or when running on a soft surface, like a sandy beach. It is also possible to have a rupture of the ligament after receiving a steroid injection for treatment of plantar fasciitis, but this is uncommon.

Pain develops suddenly and is commonly followed with bruising and swelling. The pain is worsened with walking and better with rest. X-rays should be taken, but will be negative because soft tissue is not well visualized on an X-ray.

Treatment should be a 4-8 week period of immobilization. This may require a below the knee cast, but usually involves a removable walking cast. Crutches may be needed during the first few weeks to assist in ambulation.

Calcaneal Spur Fracture: A spur can develop on the bottom of the heel in response to traction from the plantar fascia. The spur is rarely a cause of pain, but larger spurs can be broken and the events leading up to a broken heel spur (calcaneal spur fracture) are very similar to those described above for a plantar fascial rupture. Mouse over X-ray to see the spur fracture outlined.

Acute pain which develops after jumping and landing on the foot or taking off quickly in a sprint may be an indicator of a heel spur fracture. Although quick sprints, common in games like tennis or soccer, can cause a heel spur fracture, it is more likely to occur from jumping and landing on the heel.

Pain develops suddenly and is commonly followed with bruising and swelling. The pain is worsened with walking and better with rest. An X-ray will show the break at the heel spur. Treatment should be a 4-8 week period of immobilization. This may require a below the knee cast, but usually involves a removable walking cast. Crutches may be needed during the first few weeks to assist in ambulation.

Calcaneal Stress Fracture: The heel bone is called the calcaneus and is under a tremendous amount of impact when walking. Although not common, in some cases the heel bone can crack. The crack in the bone is an incomplete break, called a stress fracture.

Generally there is a deep, dull pain in the heel, at the bottom and both sides. The pain will slowly increase in intensity and is worse after walking or standing. The heel may become swollen, but is generally not bruised. The pain may develop after a change in activity, shoes or a change in a job, which may require more walking or standing. It may develop after a simple change in walking surface, but stress fractures in the heel generally do not happen after an injury or traumatic event.

An initial X-ray may not show anything – this is common with most stress fractures. Another X-ray at 4 weeks will most likely show the area of the partial break in the bone. A bone scan will show the stress fracture in it’s initial phase, but repeat X-rays may be more beneficial to evaluate the overall structure of the heel bone and to evaluate for potential collapse. Further evaluation of overall bone density to rule out osteopenia is also important.

Treatment involves a weight bearing removable below the knee cast for 4-6 weeks. Exercises such as swimming may be beneficial to maintain fitness during the recovery period.

Low Back Pain/Sciatica: Although it is unlikely to have isolated pain at the heels originating from the back, it is a possible cause of heel pain. Pain at the heels, originating from the back, may be burning, tingling or cause numbing pain. There is generally no pain when taking those first few steps in the morning (which is common with plantar fasciitis) and pain may worsen with sitting and driving. The pain may also worsen at rest or when lying down to go to sleep. Evaluation by a general physician, orthopedist or neurologist is recommended.

Nerve Entrapment: Pinching of a nerve in the heel classically develops after the initial phases of plantar fasciitis. Small tears in the plantar fascia can cause inflammation and thickening of the fascia, which can place pressure on the nerve running just beneath the fascia. Initially, pain at the first step in the morning, which seems to work itself out, is a common complaint and this is why nerve entrapment can be easily confused with plantar fasciitis. Pain generally worsens throughout the day. Tingling, burning, numbness or electrical pain may or may not be present, further confusing the diagnosis.

Heel Neuritis: Neuritis is inflammation of a nerve. In the ankle, a branch from the nerve coursing down the leg can be rubbed and irritated at the inside of the heel. The rub and irritation is generally due to shoes or orthotics. The symptoms include pain, numbness, burning, tingling and needle-like sensations.

X-rays are useful in ruling out other heel problems, but will not show any changes related to the nerve. Unfortunately, specific nerve studies (electrodiagnostic studies) are not specific for this condition. Luckily, the initial treatment for plantar fasciitis and nerve entrapment are very similar. Decreasing stress on the heel and reducing inflammation are the most effective conservative therapies. But, aggressive stretching of the plantar fascia (cornerstone treatment for plantar fasciitis) can potentially worsen the nerve entrapment. Steroid injections may be beneficial by decreasing the irritation and inflammation around the nerve. When conservative treatments fail, surgical release of the nerve may be necessary.

Tarsal Tunnel Syndrome: Another nerve problem affecting the heel is called tarsal tunnel syndrome. The sciatic nerve courses down the back of the leg and splits, giving off nerve branches along the way. Below the knee the nerve becomes the posterior tibial nerve. This is the main nerve supplying the bottom of the foot. The nerve courses down the back of the leg and around the inside of the ankle to the bottom of the foot.

At the inside of the ankle the end of the leg bone has a knobby area called the medial malleolus. The posterior tibial nerve course right behind this knob and as it heads towards the foot, it has the potential for being compressed in this area. This area is called the tarsal tunnel and is labeled in the image to the left (image copyright Primal Pictures).

Pain is generally radiates to the bottom of the foot, but sometimes up the leg. It can be dull and burning at the ankle, heel or bottom of the foot and may be sharp with walking. The pain usually worsens with activity and is only sometimes relieved by rest.

The compression can be caused by tumors, varicose veins, bone spurs, inflamed tendons, but is more commonly caused by strain on the tissue due to mechanical factors affecting the foot.

The treatment depends on the cause of the nerve compression, but generally starts with physical therapy, custom orthotics, home ice therapy and sometimes injections. If conservative measure fail, surgical release may be indicated. Any tumor or mass causing the nerve compression should be removed.

Bone Tumor: Bone tumors in the heel are fortunately rare and generally benign. The pain typically starts as a dull, deep, heel pain and then quickly worsens and is associated with swelling. An X-Ray will show a bone tumor or cyst. Depending on the level of pain and swelling and what the X-rays show, a CT scan or MRI may be recommended. Treatment depends on the type of cyst or tumor in the heel.

Arthritis: Systemic arthritic diseases can be a cause heel pain. Although conditions like rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis or Reiter’s Disease can all cause heel pain, they are not common causes. Typical treatments for conditions like plantar fasciitis may be helpful, but the underlying disease must be addressed.

Heel pain at the the back of the heel may be caused by Achilles tendonitis, heel spurs, bursitis, tenosynovitis and Haglund's deformity.

Achilles tendonitis: the inflammation of the Achilles tendon resulting from small microscopic tears within the tendon caused by chronic overuse. Achilles tendonitis typically develops after an increase or change in a certain activity. More on Achilles tendonitis/ tendinosis.

Haglunds Deformity: A bony enlargement on the back of the heel common in high arched feet and aggravated by shoes. Haglund's commonly leads to painful bursitis, the inflammation of a fluid-filled sac between the tendon and bone. Haglund’s deformity is also known as “pump bump” because the condition is common in women who wear high heels (or pumps). The rigid heel counter of a high heeled shoe aggravates the enlargement when walking. Mouse over the image to the right to see the tilt of the calcaneus.

The condition is more common in individuals with high arched feet (cavus feet) because as the heel bone tilts up in a high arched foot, the bone on the back of the heel becomes more prominent. It rubs on the Achilles tendon and shoes place more pressure on the area causing inflammation of the bursa and surrounding tissue.

Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.